Teeth grinding (bruxism) and implants

The root of a natural tooth is not attached directly to the bone; between the two is a thin layer of connective tissue called the periodontal ligament. This tissue does two jobs: it acts as a cushion by spreading the force, and its nerve endings sense pressure. It is the system that makes you ease off, as if saying 'that's enough', when you bite down very hard on something hard. An implant has no such tissue; it is in direct contact with the bone.

This has two consequences. First, the force is passed on without being spread: it bears down, undiminished, on the bridgework, the screws and the bone around the implant. Second, the feedback is weak; you cannot feel how much force you are applying as well as you can with a natural tooth. In your sleep, when conscious awareness is already switched off, this second point disappears altogether. This is why bruxism is a subject of its own when it comes to implants.

How long the force lasts matters as much as how strong it is. When you chew, your teeth are in contact for only a short time in total over the day, and each contact is brief. Grinding, on the other hand, comes as contractions lasting minutes and repeats throughout the night. In other words, the system meets a kind of loading it was not designed for: high force, for a long time, again and again.

In practice, it shows itself like this: screws that keep coming loose, cracks and fractures in the bridgework, wear on ceramic surfaces and, in some cases, bone loss progressing around a single implant. If the same screw comes loose in a patient more than once a year, night-time grinding is one of the first things that should come to mind. Simply tightening it and sending the patient away silences the symptom; it makes the cause worse.

You do not usually need someone else to tell you that you grind your teeth; the signs can be read in your mouth and your body. Tired jaw muscles in the morning, headaches that start in the temples, flattened chewing surfaces on the teeth, tooth marks along the edges of the tongue, a white line inside the cheek and muscles at the angle of the jaw that become more prominent over time. For people who make noise in their sleep, what a partner or someone else in the household says is also valuable information.

The causes cannot be summed up under one heading. Stress and anxiety are the most talked about; sleep disorders, especially sleep apnoea, are another. Some medicines, caffeine, alcohol and smoking can also make it worse. That is why bruxism is not just a matter of a night guard; dealing with the cause benefits both your mouth and your sleep.

Bruxism is not a barrier to implants; it is information that changes the planning. The points below show how that information is acted on.

Bruxism is not a habit that can be eliminated; it is a condition that is managed. These are the steps in managing it.

1. 1

   Asking about symptoms

   A tired jaw in the morning, pain in the temples, waking up with your teeth clenched, and grinding noises heard by others in the household. These are asked about before the examination, and the patient's answers change the plan.

2. 2

   Examining the signs in the mouth

   Flattened chewing surfaces on the teeth, cracks in the enamel, tooth marks along the edge of the tongue, a white line inside the cheek and prominent muscles at the angle of the jaw. These findings make visible a habit the patient is not aware of.

3. 3

   Addressing the causes

   Stress, sleep patterns, the medicines you take, and how much caffeine and alcohol you drink. If sleep apnoea is suspected, this is assessed separately; sometimes the most meaningful step in reducing grinding happens not in the mouth but in your sleep.

4. 4

   Building the plan around it

   The number and spread of implants, the length of the bridge, whether a lever arm will form and the bridgework material. Every one of these decisions changes once the fact that you grind your teeth is on the table.

5. 5

   Adjusting the bite with great care

   On the day the teeth are fitted, it is confirmed that the load is spread evenly across the supports. In a patient who grinds, a single spot that touches first turns into a blow repeated for hours every night.

6. 6

   Making and checking the night guard

   The night guard is made from an impression and checked regularly; a worn guard does not do its job. The habit of wearing it settles in over the first few weeks, and after that most patients do not find it uncomfortable.

Stopping grinding completely is often not possible; managing the load is. These are the measures that have been seen to work.

These are the most common outcomes of treatment carried out without taking grinding into account.

For a patient who grinds, treatment does not end when the teeth are fitted; the follow-up routine is half the work.

1. The first few weeks

   Your bite settles with the new bridge and the night guard comes into use. Getting used to the guard can take a few nights; a guard that feels uncomfortable at first soon becomes easy to wear, as long as it has been made accurately.

2. The first month

   The bite is measured again. In patients who grind, the small differences in how the teeth meet that appear in the first weeks are the source of long-term damage, so this check-up should not be skipped.

3. The first year

   The torque of the screws, signs of wear on the surface of the bridgework and the condition of the night guard are assessed. Wear that becomes visible on the guard is the most concrete measure of how much the grinding is continuing.

4. The long term

   Check-ups are kept more frequent than for patients who do not grind, and the night guard is replaced as it wears. This routine directly extends the life of the bridgework.

Bruxism does not change the price of treatment directly, but it does change the plan and the long-term cost. These are the items:

The extent of the load-bearing structure

For a patient who grinds, the number of implants is kept higher and their spread wider. This decision increases the initial cost but reduces the cost of repairs and replacements.

Bridgework material and how easily it can be repaired

It is not possible to rule out fractures entirely; it is possible to make repairs easier. For this group, designs that can be repaired are more economical in the long run.

Night guard

A small item with a high return. Because it needs replacing as it wears, it should be thought of as a regular item, not a one-off.

How often you have check-ups

Patients who grind have check-ups more often. This makes the long-term maintenance item a little larger; in return, catching fractures and loosening early prevents the real cost.